Rare case of self-limiting haemolysis associated with Dengue fever in a Sri Lankan female – case report

A 61-year old female with dengue haemorrhagic fever developed anaemia and rising transaminase levels on the 6th day of illness. She was found to have haemolysis with a negative direct antiglobulin test (DAT), and no red cell fragmentation. She recovered with supportive care. Haemolysis with associated Haemolytic uraemic syndrome (HUS), Disseminated intravascular coagulation (DIC) and cold Auto-immune haemolytic anaemia (AIHA) is reported previously; DAT negative haemolytic anaemia associated with dengue fever has not. This case suggests a need for further studies on other immune mechanisms that can lead to haemolysis with dengue fever.

Evaluating spatiotemporal dynamics of snakebite in Sri Lanka: Monthly incidence mapping from a national representative survey sample

BACKGROUND

Snakebite incidence shows both spatial and temporal variation. However, no study has evaluated spatiotemporal patterns of snakebites across a country or region in detail. We used a nationally representative population sample to evaluate spatiotemporal patterns of snakebite in Sri Lanka.

METHODOLOGY

We conducted a community-based cross-sectional survey representing all nine provinces of Sri Lanka. We interviewed 165 665 people (0.8% of the national population), and snakebite events reported by the respondents were recorded. Sri Lanka is an agricultural country; its central, southern and western parts receive rain mainly from Southwest monsoon (May to September) and northern and eastern parts receive rain mainly from Northeast monsoon (November to February). We developed spatiotemporal models using multivariate Poisson process modelling to explain monthly snakebite and envenoming incidences in the country. These models were developed at the provincial level to explain local spatiotemporal patterns.

PRINCIPAL FINDINGS

Snakebites and envenomings showed clear spatiotemporal patterns. Snakebite hotspots were found in North-Central, North-West, South-West and Eastern Sri Lanka. They exhibited biannual seasonal patterns except in South-Western inlands, which showed triannual seasonality. Envenoming hotspots were confined to North-Central, East and South-West parts of the country. Hotspots in North-Central regions showed triannual seasonal patterns and South-West regions had annual patterns. Hotspots remained persistent throughout the year in Eastern regions. The overall monthly snakebite and envenoming incidences in Sri Lanka were 39 (95%CI: 38-40) and 19 (95%CI: 13-30) per 100 000, respectively, translating into 110 000 (95%CI: 107 500-112 500) snakebites and 45 000 (95%CI: 32 000-73 000) envenomings in a calendar year.

CONCLUSIONS/SIGNIFICANCE

This study provides information on community-based monthly incidence of snakebites and envenomings over the whole country. Thus, it provides useful insights into healthcare decision-making, such as, prioritizing locations to establish specialized centres for snakebite management and allocating resources based on risk assessments which take into account both location and season.

Melioidosis with a subdural collection - a case report

BACKGROUND

Melioidosis is an infection caused by Burkholderia pseudomallei, which is more prevalent in the tropics and leads to significant morbidity and mortality. It characteristically produces widespread caseous lesions and abscesses, and can present with varied clinical manifestations. Melioidosis involving the central nervous system is uncommon.

CASE PRESENTATION

A 42-year-old Sri Lankan male with type 2 diabetes presented with a febrile illness of 6 days with headache and constitutional symptoms. Clinical examination was unremarkable. Four days later, he developed focal seizures involving the left leg and numbness of the left side. Initial laboratory investigations were suggestive of a bacterial infection. Blood culture was reported as positive for a Pseudomonas species, which was resistant to gentamicin. Contrast enhanced CT and MRI scans of the brain showed a subdural collection in the right fronto-temporo-parietal region with possible abscess formation. Melioidosis antibody testing using indirect hemagglutination method was reactive with a titre more than 1/10,240. He was treated with intravenous meropenem and oral co-trimoxazole for 8 weeks (Intensive phase). The subdural collection was managed conservatively, and seizures were treated with oral antiepileptics. At 7 weeks, follow-up contrast enhanced MRI showed improvement of the subdural collection, and inflammatory markers had normalized. He was discharged after 8 weeks, and treated with oral co-trimoxazole and doxycycline for 6 months (eradication phase). At 6 months follow-up, the patient is asymptomatic.

CONCLUSIONS

Cerebral melioidosis is an unusual presentation of melioidosis where the diagnosis can be easily missed. Knowledge of the protean manifestations of melioidosis is of paramount importance in order to detect and treat this potentially fatal infection appropriately, especially in tropical countries where the disease is endemic.

Evaluating temporal patterns of snakebite in Sri Lanka: the potential for higher snakebite burdens with climate change

Background

Snakebite is a neglected tropical disease that has been overlooked by healthcare decision makers in many countries. Previous studies have reported seasonal variation in hospital admission rates due to snakebites in endemic countries including Sri Lanka, but seasonal patterns have not been investigated in detail.

Methods

A national community-based survey was conducted during the period of August 2012 to June 2013. The survey used a multistage cluster design, sampled 165 665 individuals living in 44 136 households and recorded all recalled snakebite events that had occurred during the preceding year. Log-linear models were fitted to describe the expected number of snakebites occurring in each month, taking into account seasonal trends and weather conditions, and addressing the effects of variation in survey effort during the study and of recall bias amongst survey respondents.

Results

Snakebite events showed a clear seasonal variation. Typically, snakebite incidence is highest during November-December followed by March-May and August, but this can vary between years due to variations in relative humidity, which is also a risk factor. Low relative-humidity levels are associated with high snakebite incidence. If current climate-change projections are correct, this could lead to an increase in the annual snakebite burden of 31.3% (95% confidence interval: 10.7-55.7) during the next 25-50 years.

Conclusions

Snakebite in Sri Lanka shows seasonal variation. Additionally, more snakebites can be expected during periods of lower-than-expected humidity. Global climate change is likely to increase the incidence of snakebite in Sri Lanka.

Patterns and outcome of acute poisoning among children in rural Sri Lanka

Background

The burden of poisoning among children is largely underexplored in rural Sri Lanka. This study describes the patterns of demographic characteristics, poison related factors, clinical management and outcome following acute poisoning among children (9 months- 12 years) in rural Sri Lanka.

Method

This hospital based multi-center study included Anuradhapura Teaching hospital, Polonnaruwa District General hospital, and 34 regional hospitals within Regional Director of Health Services in North Central province of Sri Lanka. The study assessed clinical profiles, poison related factors, clinical management, complications, harmful first aid practices, reasons for delayed management, complications and outcomes following acute poisoning over 7 years.

Results

Among 1621 children with acute poisoning, the majority were in preschool age group. Household chemicals were accountable for 489 acute poisonings (30.2%). The most common poison was kerosene oil, followed by paracetamol. Most events occurred within their own domestic premises. Potentially harmful first aid measures were practiced by approximately one third of care givers. Reasons for delayed presentation at emergency center included lack of concern by family members regarding the urgency of the situation and lack of knowledge regarding possible complications. Complications were observed in 12.5% and the most common complication was chemical pneumonitis.

Conclusions

Children with acute poisoing in rural Sri Lanka were predominantly preschoolers. They are poisonined mostly within their own housing premises. Kerosene oil, in addition to being the most common poison, had additional risks of aspiration pneumonia following potentially hazadrous first aid measures practised by the care givers. Complications though rare were potentially preventable by community education and awareness on timely attention to seek medical care, and avoidance of harmful first aid practices.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1246-0) contains supplementary material, which is available to authorized users.

Mapping the Risk of Snakebite in Sri Lanka - A National Survey with Geospatial Analysis

BACKGROUND

There is a paucity of robust epidemiological data on snakebite, and data available from hospitals and localized or time-limited surveys have major limitations. No study has investigated the incidence of snakebite across a whole country. We undertook a community-based national survey and model based geostatistics to determine incidence, envenoming, mortality and geographical pattern of snakebite in Sri Lanka.

METHODOLOGY/PRINCIPAL FINDINGS

The survey was designed to sample a population distributed equally among the nine provinces of the country. The number of data collection clusters was divided among districts in proportion to their population. Within districts clusters were randomly selected. Population based incidence of snakebite and significant envenoming were estimated. Model-based geostatistics was used to develop snakebite risk maps for Sri Lanka. 1118 of the total of 14022 GN divisions with a population of 165665 (0.8%of the country's population) were surveyed. The crude overall community incidence of snakebite, envenoming and mortality were 398 (95% CI: 356-441), 151 (130-173) and 2.3 (0.2-4.4) per 100000 population, respectively. Risk maps showed wide variation in incidence within the country, and snakebite hotspots and cold spots were determined by considering the probability of exceeding the national incidence.

CONCLUSIONS/SIGNIFICANCE

This study provides community based incidence rates of snakebite and envenoming for Sri Lanka. The within-country spatial variation of bites can inform healthcare decision making and highlights the limitations associated with estimates of incidence from hospital data or localized surveys. Our methods are replicable, and these models can be adapted to other geographic regions after re-estimating spatial covariance parameters for the particular region.